Pediatric Choking

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Fox800

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You're working on a double paramedic ambulance, your partner has the same clinical clearance that you do. You are dispatched to an apartment complex for an 18 month old female that is choking. Upon arrival, you find the family members waiting on the sidewalk, holding the child. There is a language barrier and neither you nor your partner understand what the family is saying. It's dark outside, they hand you the child and you walk to your ambulance (since it's hard to see anything), about 15 feet away, to get some light so you can assess the patient. First responders (engine with 4 EMT-B's) are arriving as you step into the ambulance w/child. You see a well-nourished 18 month old female child, crying loudly and quite active. She is not happy that you're holding her/all the attention she's getting. Her skin is pink, warm, and dry.

After translating, the first responders figure out that her family was feeding her some popcorn when she "passed out" and they called 911 because they thought she was choking. Your physical exam reveals coarse tracheal sounds ("kind of like rhonchi") but clear lung sounds. Vital signs ar HR 180, capillary refill less than two seconds, respiratory rate of 28, SPO2 96%, first responders are working on a BP and the child is quite upset and is making their life hell at trying to get a BP. ECG shows a sinus rhythm. You go to put on an ETCO2 equipped nasal cannula but realize that it won't fit the child's face.

What else would you like to know/do?
 
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Send the firefighters back to the station to watch telly and play Scrabopogle

Have mum or dad come and sit in the ambulance and hold the child

Did she cough up or seem to swallow the popcorn?

Any sign of increased work of breathing or distress that would suggest an FBAO?
 
MrBrown said:
Send the firefighters back to the station to watch telly and play Scrabopogle

Have mum or dad come and sit in the ambulance and hold the child

Did she cough up or seem to swallow the popcorn?

Any sign of increased work of breathing or distress that would suggest an FBAO?
Click to expand...

Mom is in the front passenger seat per policy. Parents advise that she was "coughing for a little bit and then went limp/passed out." She didn't cough up anything.

Pt. is tachypneic but you don't see any cyanosis/retractions/etc.
 
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It sounds like whatever is in there might have passed or still be a partial obstruction.

Can we get a look in the airway or do a finger sweep?

Any trend in the oxygenation status of the patient, is she getting worse or is there anything to suggest there is still an obstruction?
 
Kiddo is PISSED. You can't see much but you get a decent look in the mouth and you don't see anything abnormal.

SPO2 isn't reading too well. It says "low perfusion" and isn't giving you a reading, but the kiddo keeps kicking off the lead. Partner is working on putting an adhesive SPO2 probe on the pt.'s fingers/toes.

You're holding a pediatric NRB and providing blow-by oxygen as the kid won't let you put it on her face. All of a sudden her eyes roll back in her head and she goes flaccid. By the time you reach for the pediatric BVM and grab it out of the cabinet, she's awake and crying just as loud as before. She was "out" for about 5-10 seconds.

Now what?
 
OK thats bad

We can do one of two things; we can stick with the program, see if she can tolerate a paeds NRB and take the her to the hospital because this is something over my head.

... or we can go off the program and get a little crazy and go for agressive airway management which here basically means putting her to sleep with ketamine and sux and intubating.

I'd not look past tipping her upside down and giving her a couple good back slaps like mum did when I ate the legos.

For now lets start towards the hospital yeah?
 
Alright, we're transporting to the local peds hospital (level 1 trauma, good place to be). En route, the child has several recurrences of the eyes-rolling-back/flaccid routine. Vital signs remain the same. SPO2 reads "low perfusion" or just beeps with error messages. Child remains crying loudly when awake. The periods of "going limp" last about 5 seconds each.
 
Sounds like seizure activity.

Any affects on the monitor or noticeable pulse changes during the 'brief interruption of service'.

Nystagmus?

Temp? Recent hx of illness?

Medical history/ medications?

Was there any muscle tone during the episode?
 
Good thinking mate could be some sort of seizure

Despite what the SPO2 says how does baby look? Like is she well oxygenated, not cyanotic or struggling for breath?
 
Does the child have any signs of trauma?
The eyes rolling back indicated a chance for brain injury to me.
With the low SPO2, can also indicate some shock.
 
L-O-C means G-O

Temp essential, but getting to a hospital is too. Could be the tipping point in time of a laryngeal or tracheal swelling. Maybe a bit of popcorn loitering by the epoiglottis, seizure disorder, positional apnea from a C1-C2 insult (shaken baby), or underlying cadriopulmonary condition causing syncope with excessive crying or coughing. Didi mau, dinky dau.
 
I would suspect seizure activity, and that it was simply coincidence that the kid was eating when the first one happened. Aside from the other concerns mentioned, my other concern would be that this kid is hyperventilating and low CO2 is causing "corrective" LOC.
 
Seizure could prompt the kid to aspirate.

Two for one deal.
Can you crike a kid?
 
What about something as simple as a vasovagal syncope episode with all of the emotional distress of whats going on?
 
Maintain airway > continue to monitor > transport
 
Do they have any other children. First time parents usually report the worst and usually are not a reliable source of information in my expereince.

Kids crying = good sign.

Kids fussing = good sign.

Any inspiratory stridor?

Hows her color? She nice and pink or blue on the tips?

I guess a SZ is a possibility, she been sick, temp anyone else at home sick?

As was stated above by alpha monitor airway and transport.
 
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She is screaming bloody murder and warm, pink and dry. If there was some sort of aspiration I don't believe it is causing an acute issue.

Do we get to find out what was actually going on?
 
Melclin said:
Sounds like seizure activity.

Any affects on the monitor or noticeable pulse changes during the 'brief interruption of service'.

Nystagmus?

Temp? Recent hx of illness?

Medical history/ medications?

Was there any muscle tone during the episode?
Click to expand...

No effect on the monitor/pulse changes. No nystagmus. No temperature, didn't ask about recent history of illnesses. No medical history. Child loses muscle tone during episodes.
 
MrBrown said:
Good thinking mate could be some sort of seizure

Despite what the SPO2 says how does baby look? Like is she well oxygenated, not cyanotic or struggling for breath?
Click to expand...

Pink/warm/dry skin, capillary refill <2 sec, no cyanosis noted anywhere, no retractions/head bobbing/see-saw breathing.
 
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